| NPI | 1255365193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 15615) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 25988) |
| 1223G0001X Dentist, General Practice (Licence: TX 25988) | |
| Enumeration Date | 2006-07-10 |
| Last Update Date | 2025-09-17 |